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INFECTION PREVENTION & CONTROL

CLEAN HANDS SAVE LIVES

HAND HYGIENE NEW ZEALAND EDUCATION TOOLKIT

www.handhygiene.org.nz


2

PUBLISHED IN MAY 2014:

Hand Hygiene New ZealandRinga Horoia Aotearoa Quality DepartmentAuckland District Health BoardPrivate Bag 92189Victoria Street WestAuckland 1142New Zealand

This document is also available on the Hand Hygiene New Zealand website:


DISCLAIMER

Although every effort has been made to ensure that this guidance document is as accurate as possible, the authors will not be held responsible for any action arising out of its use. District health boards and other organisations or individuals involved in implementing a hand hygiene programme should also refer directly to other documents and evidence referred to in these guidelines and decide upon the approach that is most appropriate for their particular circumstances.

CONTENTS

Hand hygiene improvement: A New Zealand perspective . . . . . . . . . . . . . . . . . . . . . . . . 5

World Health Organization 5 Moments approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Plan, Do, Study, Act . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Frontline ownership model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Principles for teaching adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Why isn’t 100% a national performance goal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Teaching tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Hand hygiene and glove use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

APPENDIX ONE: hand hygiene champion position description . . . . . . . . . . . . . . . . . . . . 25

APPENDIX TWO: PDSA cycle example . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

3HAND HYGIENE NEW ZEALAND n HAND HYGIENE EDUCATION TOOLKIT

Hand Hygiene New Zealand (HHNZ) is a national quality improvement programme that

aims to improve the quality and safety of patient care by reducing healthcare associated

infections through improved hand hygiene practice by healthcare workers in New Zealand’s

public hospitals.

It is one component of the Health Quality & Safety Commission’s Infection Prevention and Control

programme. Auckland District Health Board delivers the HHNZ programme in partnership with the

Commission.

BACKGROUND

The HHNZ education toolkit has been developed to provide district health board (DHB)

hand hygiene coordinators, champions and others, with a range of ideas and activities for

delivering hand hygiene education to healthcare workers.

The toolkit draws upon the principles of Frontline Ownership (FLO) so that the reader can devise their

own education strategy depending upon the unique needs of their hospital, service or ward.

The toolkit is intended to be practical and easily utilised. It has been developed with the input of hand

hygiene coordinators throughout New Zealand. It includes:

n The FLO framework.

n A flow chart of different activities that follow progress from standard through to expert levels of

hand hygiene implementation.

n The Plan, Do, Study, Act (PDSA) Model for Improvement.

n Examples of teaching tools that individuals can use to drive change or trigger improvement activities

among healthcare workers.

n How to use a UV light to maximise hand hygiene technique, and reduce inappropriate glove use.

n Educational tools: PowerPoints, how-to information and educational guidance.

INTRODUCTION

4 HAND HYGIENE NEW ZEALAND n HAND HYGIENE EDUCATION TOOLKIT

HAND HYGIENE IMPROVEMENT: A NEW ZEALAND PERSPECTIVE

DHBs in New Zealand are at various stages in their cycle of hand hygiene improvement.

Within each DHB, wards and units are also in various stages of improvement.

The following table is a guide for DHBs to gauge where implementation of their hand hygiene

programme currently sits. It describes the activities that support a culture of hand hygiene excellence.

By utilising tools from HHNZ we anticipate that all DHBs can develop and maintain an advanced to

expert level of hand hygiene practice.

STANDARD INTERMEDIATE ADVANCED EXPERT

• Standard operational requirements as per WHO guidelines and HHNZ Implementation Guidelines pages 20-30.

• Product at the point of care.

• HHNZ trained and certified gold auditors and gold auditor trainer.

• Reporting hand hygiene performance audit data to HHNZ.

All of STANDARD plus:

• Recruit hand hygiene champions (see page 12 of the HHNZ Auditing Manual).

• Supportive management structures with clear lines of accountability.

• Effective feedback mechanisms.

• Increased engagement of the quality, patient safety and improvement specialist teams within the DHB.

• Start the FLO ideas.

• Educational programme for hand hygiene that meets the needs of new and existing staff including education about appropriate glove use.

All of INTERMEDIATE plus:

• Start to develop strategy for patient engagement programme according to local needs.

• Implementation of FLO model across clinical areas with improvement as a result of the FLO process.

All of ADVANCED plus:

• Implementation of an appropriate patient engagement programme.

• Integration of FLO model across a range of clinical services to sustain improvement based on new cultural norms.

• Sustained hand hygiene compliance across the DHB with all areas meeting the Quality and Safety Markers and self-imposed (higher) targets.

• Full reporting schedule visible in all clinical areas and cascaded through all clinical areas.

• Utilisation of existing networks and the HHNZ programme to share successful FLO based approaches to improvement between similar services and units at a national or regional level.


STANDARD LEVEL OPERATIONAL REQUIREMENTS

It is anticipated that all DHBs have established a

local hand hygiene programme, including:

n A multidisciplinary steering group.

n A hand hygiene coordinator.

n A gold auditor trainer.

n Trained and certified gold auditors.

n Alcohol based hand rub (ABHR) product at the

point of care.

n A basic hand hygiene 5 Moment education

programme.

n A strategic hand hygiene improvement plan.

n The ability to monitor barriers to hand hygiene

improvement.

n Capability to report Staphylococcus aureus

bacteraemia data to HHNZ.

n Capability to submit national hand hygiene

performance data to HHNZ.

INTERMEDIATE LEVEL OPERATIONAL REQUIREMENTS

All of Standard plus:

n A supportive management structure with a

clear line of accountability, established through

the steering committee. The organisational

leadership prioritises quality of care, paying

attention to it regularly, creating accountability

systems and recognising success.

n Recruited hand hygiene champions (see page

12 of the HHNZ Auditing Manual and page

16 of the HHNZ Implementation Manual) who

are provided with a position description (see

example in Appendix One).

n Effective feedback mechanisms. For example,

do your DHB’s performance results trigger

improvement and PDSA cycles?

n Initiated a FLO model with support from the

quality team, improvement and educational staff

and the infection prevention and control team.

n An educational programme for 5 Moments

that meets the needs of new and existing staff

including education about appropriate glove use.

n Hand hygiene 5 Moments education is included

in orientation manuals and demonstrated to

new clinical staff.

n Established local ward auditing in non-national

reporting wards.

n Improved performance to national standards

across national wards (at least 75%

performance).

n Reviewing barriers to hand hygiene and

implementing local PDSA cycles for

improvement.


ADVANCED LEVEL OPERATIONAL REQUIREMENTS

All of Intermediate plus:

n Initiated planning for patient engagement

programme according to local needs.

n Educational programme for 5 Moments that

directly targets areas for improvement and is

used in conjunction with PDSA cycles.

n Implementation of FLO model across clinical

areas with measurement of improvement

as a result of the FLO process (can use

PDSA cycles or other improvement tools and

measurement).

n Improved performance across all wards and

units to national standard (of at least 75%

performance).

n Implementing hand hygiene programmes

across atypical non-auditing areas. For

example, operating rooms, mental health and

maternity.

n Sharing ideas and successes with other

DHBs.

n Development of a sustainability plan.

EXPERT LEVEL OPERATIONAL REQUIREMENTS

All of Advanced plus:

n Implementation of a patient engagement

programme.

n Integration of FLO model across a range of

clinical services to sustain improvement based

on new cultural norms.

n Sustained hand hygiene performance across

the DHB with all areas meeting the Quality and

Safety Markers and DHB specific aspirational

goals.

n Full reporting schedule visible in all clinical

areas and cascaded through all clinical areas.

n Utilisation of existing networks and the HHNZ

programme to share successful FLO based

approaches to improvement between similar

services and units at a national or regional

level.

n An embedded plan for sustainability that is not

person dependent but operationally viable.

n Demonstrates a sustained organisational

culture of hand hygiene excellence.


THE WORLD HEALTH ORGANIZATION 5 MOMENTS APPROACH AND MULTI-MODAL FRAMEWORK

The HHNZ programme utilises the World Health Organization’s (WHO) 5 Moments for hand

hygiene approach, which has also been adopted successfully by Hand Hygiene Australia.

This approach accounts for the fact that hand hygiene with ABHR is not only useful to

prevent transmission of pathogens between patients, but also to prevent transfer of

pathogens from contaminated to clean sites within the individual patient. Thus hand

hygiene should not only be performed before and after patient contact, but also before and

after a procedure, and after contact with patient surroundings.

The WHO multi-modal approach is the broad overarching framework used by HHNZ and DHBs to

implement the national hand hygiene programme. This high-level approach has been adopted with

great success internationally1.

IT CONSISTS OF FOUR CORE COMPONENTS:

1 System change: The placement of ABHR at the point of care.

2 Education: Hand hygiene education plus reminders and promotion in the workplace.

3 Measurement and feedback of hand hygiene performance.

4 Leadership, engagement and community organising.

Measurement and feedback of each of these components can be accompanied by improvement cycles

and initiatives. For example the PDSA cycle2 can be used as an improvement tool by DHBs (see next

page).

This process can be applied to each idea that is piloted to see if it leads to improvement on a small

scale. Successful ideas can then be rolled out more widely by wards, services or organisations,

continuing to test as they go.


The Plan, Do, Study, Act (PDSA) cycle is a way to test a change that is implemented. By

going through the prescribed four steps, it guides the thinking process to break down the

task into steps, evaluate the outcome, improve on it, and then test again.

Most of us go through some or all of these steps when we implement change in our lives, and we

don’t even think about it. Having them written down often helps people focus and learn more and can

provide a case for change for an improvement activity.

The PDSA Worksheet is a useful tool for documenting a test of change. The PDSA cycle is shorthand

for testing a change by developing a plan to test the change (Plan), carrying out the test (Do), observing

and learning from the consequences (Study), and determining what modifications should be made to

the test (Act).

PLAN, DO, STUDY, ACT

HANDY TIP:

The Institute of Healthcare Improvement has a range of useful information and

resources to help you with each step of the improvement cycle, including a PDSA

worksheet. Visit www.ihi.org/resources/Pages/HowtoImprove/default.aspx and

www.ihi.org/resources/Pages/Tools/PlanDoStudyActWorksheet.aspx.

See also the hyperlinks in the PDSA cycle diagram on the following page.


http://www.ihi.org/resources/Pages/HowtoImprove/default.aspx

http://www.ihi.org/resources/Pages/Tools/PlanDoStudyActWorksheet.aspx

The Model for Improvement: Developed by Associates in Process Improvement2

WHAT ARE WE TRYING TO ACCOMPLISH?

HOW WILL WE KNOW THAT A CHANGE IS AN IMPROVEMENT?

WHAT CHANGES CAN WE MAKE THAT WILL RESULT IN

IMPROVEMENT?

MEASUREMENT: To know whether your change is leading to the desired improvement you need to measure. The three key measures you need to consider are outcome measures, process measures and balancing measures. Measurement is a vital component of the improvement process. If you don’t measure you won’t know what impact your improvements are having on stakeholders, whether the stages of the process are working properly, whether the improvements are affecting another part of the process (IHI, 2013). www.ihi.org/knowledge/Pages/HowtoImprove/ScienceofImprovementEstablishingMeasures.aspx.

Example:

n We will audit 5 moment compliance using the gold auditor tool for 100 moments during the last two weeks of <insert your date>.

n We will audit ABHR availability at the point of care (count each bed that has one).

n We will audit and report inappropriate glove use.

AIMS: To make improvements you must first set aims. What do you want to achieve? Aims must be succinct but specific, time oriented, include numerical goals where possible (which assists with measurement planning) and send a clear message that the status quo must change. Aims should be carefully tracked (IHI, 2013). www.ihi.org/knowledge/Pages/HowtoImprove/ScienceofImprovementSettingAims.aspx.

Example: We will improve the performance of hand hygiene at the right time to achieve 10% increase on baseline for moments 1 and 2 in our preoperative areas by the end of <state your date>.

CHANGE CONCEPTS can help to inspire specific ideas for change that will lead to improvement. Change concepts are usually broad and should be combined with specific subject knowledge to determine whether they are applicable. The first Do No Harm website provides a useful list of change concepts on their website under ‘resources’. www.firstdonoharm.org.nz.

ACT PLAN

STUDY DO


http://www.ihi.org/resources/Pages/HowtoImprove/ScienceofImprovementEstablishingMeasures.aspx

http://www.ihi.org/resources/Pages/HowtoImprove/ScienceofImprovementEstablishingMeasures.aspx

http://www.ihi.org/resources/Pages/HowtoImprove/ScienceofImprovementSettingAims.aspx

http://www.ihi.org/resources/Pages/HowtoImprove/ScienceofImprovementSettingAims.aspx

THE FRONTLINE OWNERSHIP (FLO) MODEL

The FLO model is based on the principle that solutions to problems will be more effective

and resilient if frontline staff devise their own specific solutions rather than having

standardised solutions imposed on them externally3.

This approach can be particularly useful when

you are seeking to educate healthcare workers

about hand hygiene and improve hand hygiene

performance. By involving members of the

specific service or ward you are seeking to

improve behaviour among, you can work with

them to determine an approach to education that

suits their needs.

A system or mode of education delivery that

works well in one clinical setting or in one

particular service may not necessarily work

equally well in others. FLO encourages frontline

healthcare workers to come up with solutions so

that they resonate more strongly and the effects

are therefore more likely to be successful and

sustainable.

For example, in terms of practice change,

although it is clear that ABHR must be present at

the point of care to achieve good hand hygiene

practice, the optimal location of the product may

differ depending on the setting. Staff in some

intensive care units, for example, found that good

hand hygiene practice is facilitated by placing

ABHR at both ends of the patient bed. Another

critical care department has it available at all four

sides of the bed plus a hand basin within the

patient bed space.

Following some disappointing performance

results a day stay oncology team determined

that staff required greater accessibility to

ABHR to enable them to perform good hand

hygiene at the appropriate times.

Because of the tight space in between patient

zones and inability to attach an ABHR dispenser

to the chair, they found ABHR was more

accessible when it was attached to a drip pole.

They also placed additional ABHR in the middle

of the room on a trolley and each portable

trolley held a bottle of ABHR in a bracket.

A key principle of FLO is to use “positive

deviance”4. An aspect of positive deviance

is to identify staff, who despite the barriers

and obstacles, still carry out a high degree of

compliance with the action or behaviour you wish

to replicate. Observe how they manage to do this.

This information can then be passed onto to others

as tips and actions that help them to recreate this

positive deviant behaviour in their own practice.

The PDSA improvement tool is useful when

used in association with the FLO model. It can

assist ‘frontliners’ to guide and document their

improvement ideas and can demonstrate whether an

idea is useful and worth pursuing. One of the issues

that we have sometimes is that we keep doing the

same improvement activity and we expect a change

to occur and are surprised when it doesn’t.


Another aspect of this principle is to start by

working with the willing. The idea is to begin by

working with the early adopters and to work with

those who come on board to reach the early and

late majorities. Eventually you work with those

that are slower to adopt. Successes among

the early adopters are then shared more widely

among similar services or units that are slower

to embrace change. Research has revealed

that early adopters are usually people more

centrally placed within their social networks. It

was suggested that by engaging people who

were more centrally placed within their social

and professional networks, f/aster adoption and

spread of ideas, behaviour and altruism could be

achieved.


PRINCIPLES FOR TEACHING ADULTS

There are a variety of principles and theories that can guide the way you approach teaching

hand hygiene education among healthcare workers. Some useful principles are highlighted

below as a starting point for you to consider.

PRINCIPLES FOR GOOD PRACTICE WITH ADULT LEARNERS5

Malcolm Knowles established seven principles to help adults learn. The term adult covers a wide age

range and level of maturity; however, the common denominator is that we expect to see a greater

degree of independence and self-direction in adult learners. Our job as a teacher is to facilitate this.

Knowles suggested that this can be achieved by:

1 Establishing an effective learning climate, where learners feel safe and comfortable expressing

themselves.

2 Involving learners in mutual planning of relevant methods and curricular content.

3 Involving learners in diagnosing their own needs - this will help to trigger internal motivation.

4 Encouraging learners to formulate their own learning objectives - this gives them more control of

their learning.

5 Encouraging learners to identify resources and devise strategies for using the resources to

achieve their objectives.

6 Supporting learners in carrying out their learning plans.

7 Involving learners in evaluating their own learning - this can develop their skills of critical

reflection.

Your approach to teaching healthcare workers might be guided by these seven principles.


WHY ISN’T REACHING 100% A NATIONAL HAND HYGIENE PERFORMANCE GOAL?

The WHO 5 Moments of hand hygiene model teaches healthcare workers the exact moment

to complete the action of hand hygiene before, during and after patient contact.

For example, if a healthcare worker cleans his or her hands outside a curtained patient space and then

touches the curtains as they go in, they should then clean their hands again before touching the patient.

This is because curtains are considered to be contaminated. If hand hygiene is not performed again

prior to touching the patient, the opportunity to reduce the potential spread of germs from the curtain to

the patient via the healthcare worker’s hands has been missed.

As part of observing healthcare workers’ patient contact, this very robust hand hygiene auditing

approach gives no leeway for missed hand hygiene opportunities. Wards or units that are audited using

the 5 Moments approach and who consistently achieve higher than 80 per cent are understandably in

the minority.

The more acute the area is and the higher number of procedures or complex patient interactions there

are, the harder it is to achieve a higher result.

Countries that claim to be consistently in the high 90 to 100 per cent performance range would almost

certainly not be auditing using the same 5 Moments approach as described here, or be training auditors

to observe healthcare worker practice in the same way.

The best way to compare results is noting improvement within your own institution and monitoring for

sustainability.


The following section of the education toolkit highlights a variety of resources and ideas to

help you deliver hand hygiene education to healthcare workers in your DHB, service or ward.

TEACHING TOOLS

PATIENT STORIES AND ONLINE VIDEOS

As a topic hand hygiene improvement can be quite dry. Being innovative, relevant and breaking

through hand hygiene fatigue or perceptions of ‘having been here before’ can be challenging.

The use of stories and in particular patient

stories, are valuable when educating staff about

hand hygiene. Patients’ experiences can be the

catalyst that helps healthcare workers to become

motivated to improve their own hand hygiene

practice. They can also provide the impetus to

challenge or remind their colleagues about their

hand hygiene practice.

WHY DO PATIENT STORIES HELP CHANGE PRACTICE?

A really worthwhile online article by Peter Guber in

Psychology Today describes how stories can help

shape our beliefs and behaviours.

“Stories connect us to others. They provide

emotional transportation, moving people to take

action on your cause because they can very

quickly come to identify with the characters in the

narrative or share their experience—courtesy of

the images evoked in the telling,” says Peter6.

Stories allow us to simulate and learn from events

without having to live through the experience and

can involve us in personal, emotional ways. This

is different from how we respond to facts and

statistics and allows us to learn from events.

HHNZ has two patient stories that are available for

use during your education sessions. These feature

New Zealand patients sharing their healthcare and

hand hygiene related experiences.

Paul and Rachel’s story

Paul and Rachel’s story follows Paul’s experience

of undergoing ankle surgery after falling off

a ladder. Paul became critically ill with a

Staphylococcus aureus bacteraemia during his

hospital stay. Rachel and Paul both talk about

the effect that this had on them. In the video

Dr Sally Roberts, Clinical Head of Microbiology

at Auckland DHB, contributes by giving some

background around why hand hygiene is so

important in stopping such infections. Visit the

homepage of www.handhygiene.org.nz to watch

Paul’s story.


http://www.handhygiene.org.nz

Amelia’s Story

This is a written patient story and photo of

Amelia who is a teenage patient undergoing

chemotherapy at Starship Children’s Hospital.

Amelia knows an infection could be life

threatening. Amelia and her mum Kim reveal how

much good hand hygiene and cleanliness means

to them during her visits to hospital.

Visit http://bit.ly/Amelias_story to read Amelia’s

story.

Glen’s Story - You tube

Hand Hygiene Australia also has a very

moving video called “Glen’s story”. This video

is about a young Australian medical student

with leukemia and his life threatening struggles

when he acquires a healthcare associated

infection. Visit https://www.youtube.com/

watch?v=RIsBB6TmZvA to watch Glen’s story.

You could also think about creating your own

local patient story. See the Health Quality & Safety

Commission’s patient story toolkit for information

on how to develop patient story resources.

www.hqsc.govt.nz/assets/Other-Topics/QS-

challenge-reports/Patient-Stories-Toolkit.pdf

OTHER STORIES

Ignaz Semmelweiss

The story of Ignaz Semmelweiss is a great way to

open up a hand hygiene education session. There is

a lot of online information about Ignaz Semmelweiss.

It is worth familiarising yourself with his history and

the link he discovered between the high rate of

mortality in newly delivered mothers and poor hand

hygiene, while he was working as an obstetrician in

the mid to late 1840s. To find out more about Ignaz

Semmelweiss Google his name or visit

www.semmelweissociety.org/Biography.aspx

When you tell the Semmelweiss story it often

produces a sense of disbelief amongst the

audience. They cannot believe that doctors

couldn’t see the link between poor hand hygiene

and the high rates of mortality. One of the

purposes of telling this story is to talk about the

fact that despite the evidence that Semmelweiss

had, his colleagues did not want to believe it. In

fact they ridiculed it. Accordingly, they did not

want to change their practice. Years after his

death when science and proof was able to catch

up to his theory of the source of infection, he was

vindicated and is now hailed as the ‘father’ of

infection control.

Advance 150 years and the WHO have

refined hand hygiene much further and have

demonstrated that if the 5 Moments of hand

hygiene are adhered to, the outcome for patients

is much improved and their chance of receiving

a life threatening healthcare associated infection

is greatly reduced. Yet healthcare workers

are generally not convinced enough by this

information and evidence to actively change

their hand hygiene behaviour and to make it their

habit to routinely practice the 5 Moments of hand

hygiene.


http://bit.ly/Amelias_story

https://www.youtube.com/watch?v=RIsBB6TmZvA

https://www.youtube.com/watch?v=RIsBB6TmZvA

www.hqsc.govt.nz/assets/Other-Topics/QS-challenge-reports/Patient-Stories-Toolkit.pdf

www.hqsc.govt.nz/assets/Other-Topics/QS-challenge-reports/Patient-Stories-Toolkit.pdf

VIDEOS

There are several great videos available online

which have a variety of uses. Some are serious

and some are very funny. Most of these will

require YouTube access, however, if you are

unable to access YouTube at your work place

you may need to ask your IT people to download

these videos for you and put them in a format that

you can access.

Semmelweiss and Lister Blood

and guts video

The UK Blood and Guts video is very good and

captures the Semmelweiss story very well, however,

it is fairly long at 14 minutes. Watch the video here:

www.youtube.com/watch?v=wUp9mUyVIGA.

Healthcare worker hand hygiene

educational video

This is an older American video but puts the point

across very well about the chain of infection in a

busy hospital ward. Watch the video here:

www.youtube.com/watch?v=LvRP3c5n3P8.

The following two are similar but with different

music and visual effects:

n UK chain of infection video:

www.youtube.com/watch?v=_

o9SxDFPUiA.

n Wash your hands it just makes sense:

www.youtube.com/watch?v=M8AKTACyiB0.

HHNZ also has a series of competition videos,

mainly musical, which are great to put up at the

beginning of a session while people are coming

in or if you are doing a longer session they can be

useful to put up in a break. They also demonstrate

how doing something like this puts a focus on

hand hygiene and acts as a useful reminder and

engagement activity. You can access the videos

here: http://bit.ly/HHvideos.

HHNZ gold auditor training video

On the gold auditor training video there are

some good video segments that explain the

patient zone, healthcare zone, what is a patient

and what is a procedure. They also have visual

scenarios that help people understand when

they should perform hand hygiene. Your hand

hygiene coordinator will have a copy of the video

or you can request one from the HHNZ national

coordinator.


www.youtube.com/watch?v=wUp9mUyVIGA

www.youtube.com/watch?v=LvRP3c5n3P8

https://www.youtube.com/watch?v=_o9SxDFPUiA

https://www.youtube.com/watch?v=_o9SxDFPUiA

http://www.youtube.com/watch?v=M8AKTACyiB0

EDUCATING VIA A POWERPOINT PRESENTATION

There is an art to making PowerPoints interesting and relevant. ‘Death by power point’ is no fun for

anyone, particularly when talking about hand hygiene. PowerPoint slides should be a support for

your education session and use innovative or creative imagery which helps focus the audience and

engage them with your presentation.

For example, when presenting a PowerPoint and

referring to the barriers of hand hygiene you could

state that ‘sometimes you hit a brick wall’ and you

will need to find innovative ways to get around

barriers. Find images that support this analogy.

You can also theme your hand hygiene session

so that it does not have to be bland. For example,

it could be likened to playing a game of snakes

and ladders with the ups and downs. Here you

can talk about the barriers as the snakes and

the ladders as the improvement strategies or

ideas. You could also use images of dice to talk

about change (see www.rgbstock.com/photo/

mgylFfy/dices+in+hand).

Please remember that some images on the

internet may be subject to copyright but there are

free stock images available via websites such as:

n www.stockvault.net

n www.stockfreeimages.com

n www.rgbstock.com.

Please make sure that you read the terms ad

condition prior to using any images.

When delivering a presentation the main thing is

to think about your audience. A slide show for

phlebotomists will be different from one you may

deliver doctors or to students. One size does not

fit all.

There are many tips and pointers available online

on how to create and deliver effective PowerPoints.

Google “PowerPoint presentation tips”.

QUICK TIPS FOR DELIVERING EFFECTIVE POWERPOINT PRESENTATIONS7

Remember that your PowerPoint slides are there

to support, not to replace your talk. Make sure

you tell a story, describe your data or explain

circumstances, and only provide keyword/key

messages through your slides.

Here are some tips that may be useful:

n Keep the design very basic and simple. It should not distract.

n Pick an easy to read font face.

n Carefully select font sizes for headers and text.

n Leave room for highlights, such as images or take home messages. Decorate scarcely but well.

n Consistently use the same font face and sizes on all slides. Match colours.

n Express a ‘take home’ message.


http://www.rgbstock.com/photo/mgylFfy/dices+in+hand

http://www.rgbstock.com/photo/mgylFfy/dices+in+hand

http://www.stockvault.net

http://www.stockfreeimages.com

http://www.rgbstock.com

IMAGES

Images are key elements of every presentation.

Your audience has ears and eyes – they’ll want to

see what you’re talking about, and a good visual

cue will help them to understand your message

much better.

n Have more images in your slides than text.

n But do not use images to decorate!

n Images can reinforce or complement your

message.

n Use images to visualise and explain.

n A picture can say more than a thousand words.

REMEMBER YOUR AUDIENCE

n What do they know?

n What do you need to tell them?

n What do they expect?

n What will be interesting to them?

n What can you teach them?

n What will keep them focused?

n Answer these questions and boil your slides

down to the very essentials.

The World Health Organization has some useful

PowerPoint presentations about hand hygiene.

Visit www.who.int/gpsc/5may/tools/training_

education/slides/en/ for more information.

Similarly, www.slideshare.net is a useful

resource for hand hygiene PowerPoints too.

The Hand Hygiene Australia website has a series

of PowerPoint slides that you could explore.

Visit www.hha.org.au/ForHealthcareWorkers/

education.aspx.

Under the Resource Library tab on the HHNZ

website and then the ‘Presentations’ sub tab,

there is a series of PowerPoints that HHNZ and

Auckland District Health Board has delivered. You

are free to use these or select ideas from them to

form your own PowerPoints.


http://www.who.int/gpsc/5may/tools/training_education/slides/en/

http://www.who.int/gpsc/5may/tools/training_education/slides/en/

http://www.slideshare.net

http://www.hha.org.au/ForHealthcareWorkers/education.aspx

http://www.hha.org.au/ForHealthcareWorkers/education.aspx

http://www.handhygiene.org.nz/index.php?option=com_content&view=article&id=10&Itemid=114

HAND HYGIENE UV LIGHT DEMONSTRATION

The following information highlights how you can use a UV light box to demonstrate good hand

hygiene technique and also to demonstrate why gloves are not a substitute for hand hygiene.

The equipment that is required for a light box

demonstration is:

n Box of non-sterile disposable gloves

n Alcohol based hand rub (ABHR)

n Glitter bug potion (glow cream)

n UV light box and/or UV torch

n HHNZ posters: how-to hand rub and

how-to hand wash.

STEP 1. DONNING THE GLOVES

1. Assemble a box of non-sterile disposable

gloves and ABHR and invite staff to don gloves.

2. Once participants have put gloves on use

ABHR and don gloves yourself.

3. Ask: “Who has the cleanest hands now to

touch patients?” Answer: “Me, because I

have gelled my hands before donning gloves,

and anybody else who gelled their hands.”

4. Talk about the study conducted at University

of Otago8 which showed glove boxes

progressively getting more contaminated

because of non sanitised hands going into

boxes.

5. Staff that did not gel their hands have

put potentially contaminated and non-

sanitised hands into boxes. They could

have contaminated both the glove box and

gloves inside. Gloves colonised with their

flora will be transferred to other patients and

other healthcare workers when they put

contaminated gloves on.

STEP 2. GLOW CREAM APPLICATION TO GLOVES

1. Ask staff to apply glow cream to gloved

hands and rub into the gloves. Glow cream

mimics germs. You, as the presenter, do

the same.

2. Ask them to quickly remove gloves from

hands in their normal manner, and you do

this too.

3. Place hands in the light box. Alternatively

you can use UV torch. Where gloves were

removed the glow cream (aka bacteria) can

be seen on hands and small spots where

the gloves failed and also where removal of

gloves contaminated hands. Look carefully

at the finger tips, around the thumbs and

wrists and sleeves.

4. Ask those people that are ‘contaminated’

even with one tiny spot to now to stand to

one side, anyone clear of ‘contamination’

to stand another side. There are

usually approx 90% + of people on the

contaminated side. So not only do gloves

have holes, but the action of taking gloves

off contaminates hands as well.

5. Provide the following practice example:

You have helped transfer/examine a patient

or assisted in care and your gloves are

contaminated with that patient’s bacteria.

Discuss:

n Gloves are not a substitute for hand hygiene


n Gloves have minute holes and are,

therefore, semi-permeable

n The Dirty Hand in the Latex Glove9

study found that glove use was strongly

associated with lower rates of hand

hygiene compliance (58.5% failure rate

in performing correct hand hygiene with

gloves versus. 50% without glove use).

STEP 3: GLOW CREAM APPLICATION TO HANDS

1. Ask the entire group to apply cream

directly to their hands. Lightly apply and

don’t rub in. Then ask them to don gloves

again over creamed hands.

2.. Place gloved hands in the light box or use

UV torch. You can see that gloved hands

are contaminated. Remind participants

that hands need to be sanitised first before

donning gloves.

3. Place glove box in the light box or

use an UV light. The glove box is also

contaminated.

4. Provide the following practice example: Back

from lunch someone calls for assistance

and a staff member gets gloves out of a

box thereby contaminating the box. Ask:

“Who can don non-sterile gloves without

contaminating the outside of their gloves?”

No one can. The patient is now unprotected

from germs on the healthcare worker’s

hands and also from other healthcare

workers who have not sanitised their hands

before taking gloves out of the glove box.

STEP 4. REMOVE GLOVES AND WASH HANDS WITH SOAP AND WARM WATER

1. Ask staff to remove gloves and wash

hands with soap and warm water (glow

cream doesn’t come off with ABHR or

easily with cold water).

2. Light box hands again after hand washing.

This indicates where the washing

technique may have failed.

3. Demonstrate and discuss correct hand

hygiene methods using soap and water

and then using hand gel, according to

HHNZ posters or video clips.

4. This is also a good opportunity to point

out why ‘bare below the elbows’ is a good

idea. Remind people that nail polish, false

fingernails, raised rings and other hand/

wrist jewellery is not suitable for anyone

with patient contact.


STEP 5. ENVIRONMENTAL CONTAMINATION

If there is time, discuss the splash back of

bacteria and how easily it is spread. If you have a

torch, shine on clothes to see particles spread.

n Use torch if available. Check clothes, faces,

table in front of light box and door handles.

Notes

n Always use ABHR before and after glove

usage (prior to reaching into glove box). This

applies even when you are not using gloves

for direct patient care. This will ensure the

integrity of the gloves for the next healthcare

worker.

n Gloves should only be worn by healthcare

workers as an extra barrier to protect against

body fluid exposure and toxic chemical

protection. Or when directed for contact

precautions.

n Gloves should never be worn away from the

patient unless carrying body fluids to the

sluice room or blood gas machine, or when

transferring a patient known to have a multi-

resistant organism.

n Gloves are of minimal use to patients, only

useful for the healthcare worker as an extra

barrier.


There are many times when wearing gloves during patient care is important for self-

protection. But wearing gloves does not remove the need for hand hygiene. Hand hygiene

must be performed when appropriate regardless of glove use.

HAND HYGIENE AND GLOVE USE

Incorrect glove use is a barrier to good hand

hygiene practice. Gloves should only be used

by healthcare workers to protect themselves

against blood, body fluids, and toxic agents, or

for contact precautions and where indicated by

policy.

When providing healthcare workers with glove

use education be sure to highlight the following

points:

n Using sterile or non-sterile gloves does not

replace the need for cleaning your hands.

n Hand hygiene must be performed when

appropriate regardless of the indications for

glove use.

n Evidence shows that microorganism

transmission can occur from and to the

wearer’s hands via tiny holes in gloves.

n Gloves should only be worn when indicated

according to standard and contact

precautions; otherwise they become a risk for

microorganism transmission and therefore a

potential risk for patient harm.

You might also like to highlight the following tips

for performing great hand hygiene when gloves

are required:

n Clean your hands before getting gloves out

of a glove box. Putting unsanitised hands

into a glove box may contaminate remaining

gloves.

n Always clean hands before putting gloves on.

When donning gloves unsanitised hands can

contaminate the outside of the gloves (even

with gloves from ‘cuff first’ boxes).

n Always clean hands when removing gloves.

Removing gloves may contaminate your hands

with ‘splash back’. It is very difficult to remove

gloves without some residual hand, finger, or

wrist contamination.

n Always remove gloves to perform hand

hygiene when an indication occurs while

wearing gloves. Many moments are missed

through inappropriate continuous glove

wearing.

n Gloves should be removed for hand

cleaning. Alcohol based hand rub should not

be applied to the outside of gloves.

n Actively consider whether gloves are

required for the task, rather than routinely

wearing them if they are not indicated.

This information can be found in two places on

the HHNZ website. Under the Resource Library

tab and then ‘HHNZ Guidance’ you will also find

a ‘one pager’ education sheet on glove use.

The HHNZ promotional materials also include a

glove use poster that you can use to highlight

this important issue. You can find this under

the resource library tab and then ‘Promotional

Materials’.

You may also find the glove use pyramid below a

useful resource to provide to staff. The pyramid

is a modification from the WHO glove usage

pyramid www.who.int/gpsc/5may/Glove_Use_

Information_Leaflet.pdf


http://www.who.int/gpsc/5may/Glove_Use_Information_Leaflet.pdf

http://www.who.int/gpsc/5may/Glove_Use_Information_Leaflet.pdf


GLOVES DO YOU REALLY NEED THEM?

GLOVES NOT INDICATED (EXCEPT FOR CONTACT PRECAUTIONS)

No potential for exposure to blood or body fluids, or contaminated environment e.g. bedmaking,

taking vital signs.

STERILE GLOVES

INDICATED

Any sterile procedure

EXAMINATION GLOVES INDICATED IN CLINICAL

SITUATIONS

Potential for touching blood, body fluids, secretions,

excretions and items visibly soiled by body fluids.

APPENDIX ONE: EXAMPLE HAND HYGIENE CHAMPION POSITION DESCRIPTION

HAND HYGIENE CHAMPIONS

This role is important for safeguarding patient safety

by assisting in the reduction of healthcare associated

infections acquired by patients in our care.

What is my role?

n To use your knowledge and skills to support

and guide your colleagues to uphold best

practice for hand hygiene.

n Champion and lead a change in hand hygiene

practice, so teams can achieve high standards.

n Have sound knowledge of the 5 Moments and

the hand hygiene compliance auditing process.

n Be the ‘go to person’ if a member of the team

has any questions/troubleshooting.

n Elevate any concerns or possible changes

required for improvement to a charge nurse

and senior management.

n Feedback successes regarding hand hygiene

to relevant departments.

n Conduct hand hygiene performance auditing.

n Facilitate hand hygiene promotional activities

in your clinical area.

How can I do this?

n Become a HHNZ gold auditor and carry out

hand hygiene performance audits.

n Regularly assist in the presentation of

hand hygiene performance data to all ward

or department staff e.g. disseminating

performance results in your clinical area,

such as updating hand hygiene performance

posters, highlighting areas where hand

hygiene practice has improved or needs to

improve.

n Facilitate and encourage the involvement

and ownership of the excellent hand hygiene

practice within your team.

n Identify product placement, monitor

replenishment and the availability of product at

point of care. Discuss with your charge nurse

what action is required.

n Provide or facilitate education and orientation to

all new staff regarding hand hygiene products

that are used and encourage team members to

complete the online learning package.

n Advise patients and caregivers about hand

hygiene, explaining why hand hygiene is so

important.

How are you supported to be a hand hygiene champion?

n You will be trained as a gold auditor and will

have allocated time to conduct the duties as

per this position description.

n Your charge nurse will allocate the time

required to conduct the activities as per this

position description.

n You will directly report to your charge nurse on

your activities.

The DHB hand hygiene coordinator will answer

any queries and provide up to date hand hygiene

information.


APPENDIX TWO: PDSA CYCLE EXAMPLE

Although the following example is not specifically about hand hygiene, it demonstrates how

the PDSA cycle can help you to make improvements through focused planning and action

relating to a specific task.

DO: STEPS TO EXECUTE:

1. Talk to department manager re approval to

do an email/letter activity.

2. Draft the email/letter, which is then

approved and signed by department

manager.

3. Email and/or send out a letter to remind

doctors that the hospital policy requires

them to wear clean aprons for each

endoscope case by the end of the week.

4. Will try this for one month.

WHAT DID YOU OBSERVE?

n All emails and letters went out the following

week.

n There was minimal improvement. None of the

doctors mentioned the emails/letters.

n When asked, some doctors said they had not

read the email or the letter because they were

too busy.

n One doctor said he would still rely on the

nurse to tell him when to change his apron.

A nurse had been trying for five to six years to

get medical staff to change their disposable

aprons between endoscope procedures, as per

the hospital policy. When asked what it was she

was currently doing to get them to change their

aprons, she said that she felt every time she had to

verbally remind medical staff that an apron change

was indicated and if she was not there at the

appropriate time then she was not sure that they

would change their apron, also she did not want to

take responsibility for their actions anymore.

A suggestion was to implement an alternative

idea to that of verbally reminding the doctors

because clearly it was not working and was reliant

on a reminder person being there. This was not

a sustainable or reliable process or what the

reminder person wanted to keep doing.

After some brain storming the following is an

example of what she felt she could try, using the

PDSA cycle.

Tool: Improving doctors’ apron change

compliance between patients.

Step: Change in apron wearing behaviour - cycle

1st try.

I hope this produces: All doctors performing

endoscopies routinely change their aprons in

between cases without verbal reminders.


STUDY: DID YOU MEET YOUR MEASUREMENT GOAL?

No, the email and letters did not work well. No

doctors were seen to change their behaviour.

ACT: WHAT DID YOU LEARN/CONCLUDE FROM THIS CYCLE?

n The emails and letters had no effect did not

change behaviour.

After further discussion with the endoscopy team

including a doctor representative, the following

was put forward:

PLAN:

Tool: Improving doctors’ apron change

compliance.

Step: Change in apron wearing behaviour - cycle

2nd try.

I hope this produces: All doctors performing

endoscopies routinely change their aprons in

between cases without verbal reminder.

STEPS TO EXECUTE:

1. Do two designs for desktop image – have

doctors vote on the one they like best and

reminds them to change their apron in

between cases.

2. Place sign by the hand hygiene product

and glove boxes to remind doctor’s to

change aprons.

3. During the set up for each procedure

implement placement of a clean apron on

the endoscopy trolley.

4. Add this step to the procedure information.

5. Add the process to the set up list in the set

up room and make sure all endoscopy staff

are aware of the new set up.

6. Advise the doctors of new process to enable

them to easily achieve apron change.

7. Place bins near to trolley for apron

disposal.

8. Do this for one month.

DO: WHAT DID YOU OBSERVE?

n Only one doctor was verbally reminded to

change their apron and this was because they

had been on leave and not aware the process

to put a clean apron on the trolley during set

up had changed.

n All other doctors routinely changed their apron

when they were moving to the next case.

n Although staff were ok with the procedure some

of the processes to help achieve this were

missing and some barriers needed addressing:

n No rubbish bin for all the used aprons

routinely placed near the trollies.

n No hook was available to hang the apron

dispenser in the procedure room.

n Procedure list was re-written but not put in

the communications book or info circulated

to staff that had been away so they had not

reason to look at the set up list.

n Running out of aprons.


n Unsure whether desktop had an impact

because the image was not seen very much

as patient notes were up on the screen.

n Doctors said the reason they changed their

apron was because it was right in front of

them as a reminder.

n The bins got full quite quickly.

STUDY:

What did you conclude from this cycle?

The change in process of having an apron on the

trolley for each set up was effective. A few more

operational interventions were required to make

the change sustainable:

9 Acquire extra rubbish bins to be near

endoscope trolley for apron disposal.

9 Ask for a hook to be installed in the set up

room to hang aprons dispenser.

9 Write the changes in the comms email to all

staff not just verbalise at staff meeting.

9 Have the change written on bright paper with

an arrow pointing to the new step.

9 Increase the impress order for aprons.

9 The cleaner was advised of the new bin

position and the increase in emptying that was

required.

9 Reassess in one month to make sure the extra

interventions are completed.

9 Because of so many interventions it was

difficult to assess which ones worked well.

9 For next PDSA aim for smaller set of

interventions to test them more easily.

ACT: DID YOU MEET YOUR MEASUREMENT GOAL?

Yes.


1. Allegranzi B, Gayet-Ageron A, Damani N, Bengaly L, McLaws ML, Moro ML, Memish Z, Urroz O,

Richet H, Storr J, Donaldson L, Pittet D. (2013). Global implementation of WHO’s multimodal

strategy for improvement of hand hygiene: a quasi-experimental study. Lancet Infectious

Diseases, 13: 843-51.

2. Langley GL, Nolan KM, Nolan TW, Norman CL, Provost LP. (2009). The Improvement Guide:

A Practical Approach to Enhancing Organizational Performance (2nd edition). San Francisco:

Jossey-Bass Publishers.

3. Zimmerman B, Reason P, Rykert L, Gitterman L, Christian J, and Gardam M. 2013. (2013). Front-

Line Ownership: Generating a Cure Mindset for Patient Safety. Health care papers, 13:6-22.

4. Marra A, et al. (2013). A multicenter study using positive deviance for improving hand hygiene

compliance. American Journal Infection Control, 41: 984-8.

5. University of Auckland, Faculty of Medical and Health Sciences. (2010). What is the best teaching

approach? www.fmhshub.auckland.ac.nz/1_6.html?t=1367984523.34. Accessed on 26 May 2014.

6. Guber P. (2011). The Inside Story. Psychology Today.

www.psychologytoday.com/articles/201103/the-inside-story. Accessed on 26 May 2014.

7. MakeUseOf.com 10 PowerPoint Tips:

www.makeuseof.com/tag/10-tips-for-preparing-a-professional-presentation/.

Accessed on 26 May 2014.

8. Hughes KA, Cornwall J, Theis JC, Brooks HJ. (2013). Bacterial contamination of unused, disposable

non-sterile gloves on a hospital orthopaedic ward. Australasian Medical Journal, 6: 331-8.

9. Fuller C, Savage J, Besser S, Hayward A, Cookson B, Cooper B, Stone S. (2011).

“The dirty hand in the latex glove”: A study of hand hygiene compliance when gloves are worn.

Infection Control Hospital Epidemiology, 32: 1194-9.

10. Institute for Healthcare Improvement. (2014).

www.ihi.org/resources/Pages/Tools/PlanDoStudyActWorksheet.aspx

Accessed 26 May 2014.

REFERENCES


http://www.ncbi.nlm.nih.gov/pubmed/23972825


https://www.fmhshub.auckland.ac.nz/1_6.html?t=1367984523.34

http://www.psychologytoday.com/articles/201103/the-inside-story

http://www.makeuseof.com

http://www.makeuseof.com/tag/10-tips-for-preparing-a-professional-presentation/

http://www.makeuseof.com/tag/10-tips-for-preparing-a-professional-presentation/



http://www.ihi.org/resources/Pages/Tools/PlanDoStudyActWorksheet.aspx


NOTES

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